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GARFIELD COUNTY BUILDING AND SANITATION DEPARTMENT Permit
4385
108 Eighth Street, Suite 201
Glenwood Springs, Coloradof 81601
Phone (970) 945-8212
INDIVIDUAL SEWAGE DISPOSAL. PERMIT
PROPERTY
Assessor's Parcel No.
This does not constitute
a building or use permit.
Oa
Owner's Name tvot j Ki' Present Address ULYt 5e Phonq'Yr– " C 0
L o1 C. - 3 t l -
System Location
Legal Description of Assessor's Parcel No
--irckit A-001)-P-irs ordAGut(
SYSTEM DESIGN
Septic Tank Capacity (gallon) Other
Percolation Rate (minutes/inch) Number of Bedrooms (or other)
Required Absorption Area - See Attached
Special Setback Requirements:
Date inspector
FINAL SYSTEM INSPECTION AND APPROVAL (as installed)
Cali for Inspection (24 hours notice) Before Covering Installation
System Installer
Septic Tank Capacity
Septic Tank Manufacturer or Trade Name
Septic Tank Access within 8" of surface
Absorption Area
Absorption Area Type and/or Manufacturer or Trade Name
Adequate compliance with 4unty d State regulations/requirements
Other
Date
Inspector
yvA
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All installation must comply with all requirements of the Colorado State Board of Health Individual Sewage Disposal Systems Chapter
25, Article 10 C.R.S. 1973, Revised 1984.
2. This permit is valid only for connection to structures which have fully complied with County zoning and building requirements. Con-
nection to or use with any dwelling or structures not approved by the Building and Zoning office shall automatically be a violation or a
requirement of the permit and cause for both legal action and revocation of the permit.
3. Any person who constructs, alters, or installs an individual sewage disposal system in a manner which involves a knowing and material
variation from the terms or specifications contained in the application of permit commits a Class 1, Petty Offense ($500.00 fine — 6
months in jail or both).
to/ufc _ ADDI tr`AKIT Vtallrnu _ rmott iTt,AG(\IT
OWNER
INDIVIDUAL SEWAGE DISPOSAL SYSTEM APPLICATION
614,4
ADDRESS / 6 r -2 3 3' d._,_ PHONE %'-'..7`)
CONTRACTOR
ADDRESS PHONE
99a -wog
PyERMIT REQUEST FOR e ) NEW INSTALLATION ( ALTERATION ( ) REPAIR
ttach separate sheets or report showing entire area with respect to surrounding areas, topography of area,.halitable
building; --location of potable water wells, sail percolation test holes, soil profiles in test holes.(See-rpage 4).
LOCATION OF PROPOSED FACILITY:
Near what City of TownSize of Lot L
Legal Description or Address Lk S"U 1 C.A. Z T
WASTES TYPE:
) DWELLING
( ) COMMERCIAL OR INDUSTRIAL
( ) OTHER - DESCRIBE
(
(
TRANSIENT USE
.NON-DOMESTIC WASTES
,,,a1 I DING rOR SERVICE TYPE: F
Number of Bedrooms m�., �, . NumberAo Pe ons
- ) Garbage -Grinder -'':L (4.) Automatic Washer ishwasher
SOURCE AND TYPE OF WATER SUP:PLY4—(..WEL- WELL—
If.ww..
If supplied by Commutiity Water, give name of supplier:
DISTANCE TO NEAREST COMMUNITY SEWER SYSTEM
Was an effort made to connect to the Community System?
A site s Ian is re 1 uired to be submitted that indicates the foliowin
MINIMUM distances:
Leach Field to Well:
Septic Tank to Well:
Leach Field to Irrigation Ditches, Stream or Water Course:
100 feet
50 feet
50 feet
Septic System (septic tank & disposal field) to Property Lines: 10 feet
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITHOUT
A SITE PLAN.
GROUND CONDITIONS:
Depth to first Ground Water Table
Percent Ground Slope
2
TYPE OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM PROPOSED:
(^, SEPTIC TANK
VAULT PRIVY
PIT PRIVY
CHEMICAL TOILET( )
AERATION PLANT
) COMPOSTING TOILET
) INCINERATION TOILET
OTHER -DESCRIBE
FINAL DIS4
POSAL, BY
(✓ABSORPTION TRENCH, BED OR PIT
( ) UNDERGROUND DISPERSAL
( ) ABOVE GROUND DISPERSAL
( ) OTHER -DESCRIBE
(
(
(
) VAULT
) RECYCLING, POT i 43LE USE
4
) RECYCLING, OTHER USE
( ) EVAPOTRANSPIRATION
( ) SAND FILTER
( ) WASTEWATER POND
WILL EFFLUENT BE DISCHARGED DIRECTLY INTO WATERS OF THE STATE?
PERCOLATION TEST RESULTS: (To be completed by Registered Professional Engineer, if the Engineer does the
Percolation Test)
Minutes
Minutes
per inch in hole No. 1
per inch in hole No. 2
Minutes
Minutes
per inch in hole No. 3
per inch in hole No. _
Name, address and telephone of RPE who made soil absorption tests:
Name, address and telephone of RPE responsible for design of the system: CI 41,-1,6 t- 45-4 C_
Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and
additional tests and reports as may be required by the local health department to be made and furnished by the applicant
or by the local health department for purposed of the evaluation of the application; and the issuance of the permit is
subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations made,
infoi.nnation and reports submitted herewith and required to be submitted by the applicant are or will be represented to
be true and correct to the best of my knowledge and belief and are designed to be relied on by the local department of
health in evaluating the same for purposes of issuing the peiiait applied for herein. I further understand that any
falsification or misrepresentation may result in the denial of the application or revocation of any permit granted based
upon said application and in legal action for perjury as provided by law.
PLEASE DRAW AN ACCURATE MAP TO YOUR PROPER'T'Y!!
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